Correction of Anterior Crossbite Due to Tooth Loss with Early Elastics

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1 Correction of Anterior Crossbite Due to Tooth Loss with Early Elastics Clinician: Dr. Ramon Perera, Lleida, Spain Patient: A.R. Class I & III Anterior Crossbite Pretreatment Diagnosis Skeletal Class I, dental Class III, female patient, age 32 years 6 months, presented to us for a second opinion. She was worried about her anterior crossbite due to previous extraction of her upper 1st bicuspids. Another orthodontist had recommended extracting two teeth from the lower arch, a recommendation she did not find acceptable. Facial/Soft Tissue/Macroesthetics Brachyfacial with normal facial heights and a good profile with a well-proportioned chin-to-nasolabial relationship. A slight lack of upper lip projection that was made more evident by a rather large nose. Full and slightly protruding lower lip due to the forward position and proinclination of the lower incisors. Thin and slightly recessive upper lip. Lack of midface support. Exposure of the lower incisors when the lips were in a relaxed position. Smile/Miniesthetics Symmetrical smile with a consonant smile arc. Little upper incisor display with no gingival exposure on smiling. Upper midline centered. Narrow smile (to the upper first bicuspids) without large buccal corridors. The esthetics of the smile is adversely affected by the presence of a large interincisal diastema. Teeth/Microesthetics Pleasing tooth shape, shade and gingival contours. Small contact areas between the central and lateral upper incisors with no black triangular holes. An absence of contact between the upper central incisors due to the diastema. Anterior crossbite due to the previous extraction of the upper 1st bicuspids. Proclination of the upper canines and lower incisors. Initial Appliance Used Damon 3MX 51

2 Treatment Objectives and Plan Employing Damon 3MX (D3MX) passive selfligating appliances, achieve a functional occlusion, resolve the anterior crossbite and enhance facial and smile aesthetics by increasing the upper lip projection, upper incisor display and the smile width with exposure of the upper 2nd bicuspids on smiling. Attempt to correct the malocclusion with Class III elastics, but if that plan does not prove possible, open space for implants in the maxilla. Discarded the option of lower extractions. Damon 3MX Variable Torques Employed U1s: Low torque (+7 ) U2s: Low torque (+3 ) U3s: Standard torque (0 ) L1-2: Low torque (-6 ) L3s: Super torque (+7 ) Employ low-torque brackets on the upper incisors to prevent the flaring of those teeth while using Class III elastics (or if we later choose to open maxillary space). Treatment Sequence Bonding U/L: Direct-bonded U/L 6-6, engaging.014 round Damon Optimal Force Copper Ni-Ti 1 archwires, cutting the wire distal to the 6s. Bonded posterior bite planes using Resilience blue light-cure band cement (Ortho Technology, Tampa, FL) on the U6s to disarticulate the arches and facilitate the work of the CL III elastics. (If we were to treat this case today, we would fit bite turbos on the lingual surfaces of the L1s.) Started Quail, 3/16, 2 oz., Shorty CL III elastics (bilaterally L3 to U5, full-time). Placed stops mesial and distal to UR1 and LL1. In cases with an interincisal diastema, it is not recommended to put both stops between the U1s. Bonding 1 All Copper Ni-Ti wire used is Damon Optimal Force Copper Ni-Ti. 52

3 2.5 Months U/L: Bonded the 7s, extending the wires to them. Maintained the Shorty CL III elastics, but advanced to Otter, 3/16, 3 oz., bilaterally L3 to U5, fulltime. U: Transitioned to.016 CuNi-Ti, moving the stops mesial and distal to UR3. Normally, when there is no crowding, we fit the stops mesial and distal to a bicuspid (not the cuspids). L: Transitioned to.014 x.025 CuNi-Ti archwire in the lower arch, maintaining the stops mesial and distal LL Months 5 Months U: Transitioned to.018 x.025 CuNi-Ti archwire, placed power chain U3-3 and moved stops mesial and distal to UR5. L: Initiated slight IPR L2-2 to improve their contact areas, placed one stop between the L1s and placed power chain L3-3, but towards the occlusal edge (over the 1s and 2s) to achieve a greater retroclination effect. Maintained the.014 x.025 CuNi-Ti archwire. U/L: Transitioned to full Class III elastics full-time, bilaterally, Kangaroo, 3/16, 4.5 oz. Even though we moved from Shorty to full Class III elastics, we continued the same length elastics (3/16 ) because, with the absence of the U4s, there had been too much slack in the elastics so they did not produce the desired effect. 5 Months 53

4 6.5 Months U: Maintained.018 x.025 CuNi-Ti archwire, moving stops mesial and distal to UL5. L: Transitioned to a.018 x.025 CuNi-Ti archwire, moved the stops mesial and distal to LR5 and renewed the power chain L3-3, again fitting it toward the incisal edges. U/L: At this appointment, we were pleased to see the positive effects of the Class III elastics over the previous 1.5 months, which confirmed that in the first 5 months of treatment, the elastics had not had the desired effect because the length was too great given the absence of the extracted teeth. Maintained the full Class III elastics, full-time. 6.5 Months 54

5 9 Months U/L: Took an interim panograph and rebonded UR7, UR2, UL1, UL5, LL5 and LL7. Maintained the.018 x.025 CuNi-Ti archwires, the stops (mesial and distal to UR5 and LR5) and ligature-tied U/L3-3. Maintained the full Class III elastics full-time. At this point, the Class III is corrected and the facial esthetics have improved (upper lip projection, smile width, midface support, etc.). 9 Months 55

6 10.5 Months U/L: Transitioned to preposted.019 x.025 stainless steel archwires, fitting tie-backs to keep the posterior spaces closed (L6 over 4 to post mesial to L3 and U6 under 5 to post mesial to U3), widening the upper archwire (standard Damon arch form) 5 mm in the posterior bilaterally. Added tip-backs in the upper and lower molar regions to prevent molar extrusion. Continued ligation U/L 3-3 and Class III elastics, transitioning to Impala, 3/16, 6 oz., full-time Months 12 Months U: Maintained the.019 x.025 stainless steel archwire with the posterior expansion and tipbacks, ligation U3-3 and the tie-backs in the buccal segments. L: Transitioned to a.016 x 025 stainless steel wire on the lower arch to facilitate intercuspation. Transitioned to Moose elastics, 5/16, 6 oz. in a tent configuration (L4 to post mesial to U3 to post mesial to L3) full-time, to stabilize the Class I relationship and close the bite. Maintained the ligation L3-3 and tie-backs in the buccal segments. 12 Months 56

7 15 Months U: Performed additional IPR on the incisors to improve the contact areas. Transitioned to.019 x.025 purple TMA archwire, adding labial root torque to the UR3, bending the wire distal to the 7s. Engaged power chain U6-6. We used the lowfriction TMA archwire because of the IPR. L: Transitioned to a.017 x.025 TMA archwire. There were no spaces on the lower arch so it was not necessary to use a power chain for space closure; however, because it was not possible to bend the lower archwire on the distal side (note the stops mesial and distal to LR5), I used a power chain L6-6 to prevent new spaces from opening. U/L: Began 1/8, 6 oz. triangular finishing elastics (Ceosa Orthodontic Manufacturing, Madrid, Spain) on the canines (U3 to L3 and L4) and bicuspids (U5 to L4 and L5) and Impala 3/16, 6 oz. posterior box elastics on the molars (U6 and U7 to L6 and L7), full-time. 15 Months 16 Months U/L: Maintained archwires, power chain and elastics attachments. 16 Months 57

8 17 Months Final Visit, 68 Weeks 11 Treatment Visits, 2 Emergency Visits U/L: Removed all appliances. Direct bonded fixed permanent retainers U2-2 and L3-3, using Ortho FlexTech gold chain (Reliance Orthodontics, Itasca, IL) and took impressions for a Damon Retention Splint (AOA, Sturtevant, WI) to be worn at night for one year. 17 Months - Treatment Complete 58

9 Case Discussion We achieved all the primary treatment goals. With the correction of the anterior crossbite, the patient now has a functional occlusion and her facial and smile esthetics have improved (improved upper lip projection, increased smile width and exposure of the 2nd bicuspids on smiling). Thanks to the power of early elastics, the Class III canine relationship and the anterior crossbite were corrected without opening any space on the upper arch or having to extract on the lower arch. Generally speaking, it is very important to use extremely light forces with nickel-titanium archwires. In this case, after nine months of treatment with early elastics, we already knew that the space opening on the upper arch would not be necessary. If we had not used elastics from the beginning, we would have had to spend much more time in the stainless steel archwire phase, and if Class III elastics had not been adequate, we would have had to begin opening space for upper bicuspids after one year of treatment or more. If lower arch extractions had been the treatment choice, the result would have been far less attractive and the patient s facial aesthetics would have been compromised. We would have reduced her lower lip instead of increasing the projection of her upper lip, which would have left her entire profile more retruded. Particularly in this case, such retrusion would have been accentuated by the prominence of the patient s large nose. We bonded low-torque brackets on the upper incisors because either of the two possible treatment options (Class III elastics or space opening on the upper arch) would have resulted in proinclination of the incisors, which the lowtorque brackets would have served to mitigate or even preclude. proclined at the start of the treatment. Had we treated this case later using the Damon Q (DQ) appliance, we would probably have bonded standard torque on the lower incisors (-3 ) because low torque (-11 ) would have been excessive in this case since there was no crowding on the lower arch. We would then have used Class III elastics. If we had treated the case by opening space on the upper arch (without using Class III elastics), DQ low-torque brackets would have been the appropriate choice. The Damon System appliance offers a variety of different torque options. It is important to carefully select the required torque based on a number of parameters: (1) The initial position of the tooth and (2) The nature of the malocclusion and how it must be resolved (e.g., if it is necessary to use Class II or Class III elastics, whether there is crowding and how severe it is, if it is necessary to align the curve of the Spee and if there will be extractions, etc.). If we do not apply the correct bracket torque, the treatment will take longer because we will have to resolve torque problems that we ourselves have caused. We regard the stainless steel archwire phase as finished when all the anterior-posterior, transverse and vertical problems have been resolved. After that, the only remaining work is to improve the intercuspation and, if necessary, to add individual tooth torque refinements and/or insets and offsets to the archwires. For this reason, we do not think that it is typically necessary to continue stainless steel archwires for an extended period of time. We bonded low-torque brackets on the lower incisors (-6 ) because we were not sure that we could correct the malocclusion using only Class III elastics (due to potential space opening on upper arch) and because the lower incisors were already Initial Final 59

10 What I Would Do Differently Today Despite bonding standard torque brackets on the upper canines (0 ), their initial proclination and the use of Class III elastics mandated that we apply labial root torque to the TMA archwire at the UR3. Were I to treat the case today, I would use the DQ standard-torque brackets (+7 ) on these teeth because low-torque brackets (-9 ) would be excessive. We would probably, however, have to invert the brackets (-7 ) either before or after the stainless steel archwire phase in order to correct the upper canine proclination. I also think that we should have extruded the upper incisors a little more, thereby increasing their exposure on smile and improving the smile arc. We should also have intruded the lower incisors to minimize their exposure when the mouth is in a relaxed position. I would like to thank my collaborator, Dr. Jessica García, for all the help she has given me in the treatment of this patient, the selection of the photographs and the preparation of the case report. 60

11 Wire Sequence Chart Clinician: Dr. Ramon Perera, Lleida, Spain Patient A.R. Maxillary Hardware Mandibular Hardware Herbst\Elastics 0 Weeks 10 Weeks 5 Weeks 15 Weeks 20 Weeks 25 Weeks 30 Weeks 35 Weeks 40 Weeks 45 Weeks 50 Weeks 55 Weeks 60 Weeks 65 Weeks 70 Weeks START.014 CuNi-Ti.014 CuNi-Ti Shorty CL III Elastics, L3 to U5, Quail, 3/16, 2 oz..016 CuNi-Ti.014 x.025 CuNi-Ti Shorty CL III Elastics, L3 to U5, Otter, 3/16, 3 oz..018 x.025 CuNi-Ti.018 x.025 CuNi-Ti Full CL III Elastics Kangaroo, 3/16, 4.5 oz..019 x.025 Stainless Steel.019 x.025 Stainless Steel Full CL III Elastics, Impala 3/16, 6 oz..016 x.025 Stainless Steel Tent Elastics, Moose, 5/16, 6 oz..019 x.025 Purple TMA.017 x.025 TMA Triangular f inishing elastics on canines and bicuspids, 1/8, 6 oz.*, full-time Posterior Box elastics, Impala, 3/16, 6 oz., on molars *Ceosa Orthodontic Manufacturing, Madrid, Spain FINISH 61

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